Date of Completion
Fall 2026
Document Type
DNP Scholarly Project
Academic Department
School of Nursing
Degree Type
Doctoral
Degree Name
Doctor of Nursing Practice
First Advisor
Dr. Katie Hooven
Second Advisor
Dr. Melanie Brewer
Abstract
Background: Ineffective communication during transitions from acute care hospitals to skilled nursing facilities (SNFs) contributes to avoidable bed days (ABDs), prolonged length of stay (LOS), and discharge delays. Although evidence-based tools such as InterQual and Milliman Care Guidelines supported clinical decision-making, a standardized communication process among case managers, social workers, payers, and SNF partners was lacking. This program evaluation examined the effectiveness of a standardized CareHub communication workflow designed to improve discharge coordination and transitions to SNFs.
Methods: Guided by the Centers for Disease Control and Prevention Program Evaluation Framework, a 90-day program evaluation (February-April 2026) was conducted in a 700-bed Southern California hospital. Process, outcome, and impact measures included workflow adherence, communication consistency, discharge-planning activities, LOS, ABDs, and stakeholder perceptions. Quantitative data were analyzed using descriptive statistics, and qualitative feedback was analyzed using thematic grouping.
Results: The CareHub workflow was implemented for 226 patients across three hospital units. During the pilot, case managers completed 1,035 referrals, 198 authorizations, and 350 follow-up activities. Workflow adherence exceeded the 90% target, demonstrating strong implementation fidelity. Care conferences increased by 26%, patient and family discharge-planning meetings increased by 22%, and patient discharges increased by 21%. ABDs decreased by 34.6%, from 535 to 350 days, while LOS decreased by 26.1% to 36.5% across participating units. Estimated cost avoidance totaled approximately $370,000 during the evaluation period.
Conclusions: The standardized CareHub communication workflow improved communication consistency, discharge coordination, and operational efficiency while reducing discharge delays, LOS, and ABDs. Findings support the sustainability and broader adoption of standardized communication workflows to strengthen transitions to SNFs and improve organizational performance.
Recommended Citation
Choudhury, Rachel, "Program Evaluation: Effectiveness of Case Management CareHub for Skilled Nursing Facility Transitions" (2026). All Doctor of Nursing Practice (DNP) Scholarly Projects. 92.
https://fuse.franklin.edu/dnp-project/92
Rights
Copyright, all rights reserved
Included in
Health Services Administration Commons, Other Nursing Commons, Public Health and Community Nursing Commons, Quality Improvement Commons
